Provider Demographics
NPI:1568575363
Name:JAQUES, SUSAN H (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:H
Last Name:JAQUES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 BURCH FORD RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29059
Mailing Address - Country:US
Mailing Address - Phone:803-496-9012
Mailing Address - Fax:803-496-7054
Practice Address - Street 1:303 BURCH FORD RD
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059
Practice Address - Country:US
Practice Address - Phone:803-496-9012
Practice Address - Fax:803-496-7054
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC992538Medicaid